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Sunday, June 16, 2013

Health Insurance

What is it they say about the best made plans? Well, in the middle of my search for a boat, life has thrown me a little curve ball. A few days ago I had to go in for a minor outpatient surgery. I'm at home recovering now and everything should be OK, but it has put my search on hold for just a little bit.

This got me thinking about healthcare again. Of course right now I, like many working stiffs in the U.S., have health insurance provided by my employer. Over the past years the portion of this insurance that the employee pays for has gone up considerably while the coverage seems to have gone down. While I haven't received the final bill, between all the deductibles and copayments and multiple billings. I expect I will owe several thousand dollars...for this outpatient procedure.

I'm pretty sure that for the cost I'll end up paying myself, I probably could have flown to one of a number of places where healthcare is both decent and affordable. If I had been able to think straight at the time, I should have looked into this. Maybe I could have been recuperating in some tropical locale where I could look at some boats instead of sitting at home. Oh well.

General Hospital in St George's, Grenada

In the U.S. we always hear that we have the best healthcare in the world. (We should tout that we have the best propaganda and advertising in the world). While I'm sure we have some very cutting edge research and procedures that can better save lives here, I think the truth is that for most of the average working stiffs in the U.S. our medical care is determined mostly by an insurance company that works as a for-profit business. Their primary concern is to make a profit for their shareholders and their secondary concern is selling their insurance to the companies we work for as a reasonably cost-effective "benefit". The end result is that I doubt most of us actually have direct access to the "best" due to the prohibitive cost and lack of coverage by our insurance providers. When pitting my well-being against the profit of a corporation, I don't think I'll be betting on my well-being as the insurance company's primary motivating factor. So, this leaves most of us with more "average" healthcare.

I have a friend whose father retired to Mexico a number of years ago. As with most traditional retirement-aged folks, they have had somewhat regular experience with the medical care there. The father is happy with the healthcare he has received and finds that the quality of care is very similar to that found in the U.S., with many of the doctors and specialists actually U.S. trained. The difference is that the cost is significantly less, on the order of 25% to 33% of what comparable care costs in the U.S. By the time I calculate what I've paid in insurance premiums and what I'll pay in deductibles, co-payments, and co-insurance (a fancy term for a percentage that you will have to pay out-of-pocket anyway), I'm pretty sure I'll have paid for more than 33% of my U.S. priced medical care this year.

The only thing that the insurance companies seem to really do for us is to negotiate somewhat more reasonable rates with medical providers (you know, when the doctor charges you $100 for something, the insurance says they apply a "discount" and the charge is reduced to $10). Ironically, this isn't that different from the cost controls used in many of the public healthcare systems in the rest of the world.

When I was doing research on this subject a while ago, I ran across an insurance company that would provide international health insurance. I don't recall the exact figures but from what I could remember at the time, I could get insurance for my wife and me that would cover us everywhere except the U.S. and it seemed fairly reasonable. If we wanted to add coverage in the U.S., the cost of coverage was multiplied by a factor of about 8. So, apparently the U.S. does have the most expensive healthcare in the world.

It seems in most cases we plan to be in places that will have decent healthcare at reasonable prices. So, do we simply "self insure" (a.k.a. pay our own way)? Buy a policy with a high deductible that would cover more catastrophic issues? Should we consider some sort of evacuation plan (can fly you to somewhere with better medical care if you are not near facilities that can help)? Lots of questions to be answered. Depending on the cost, I think we will likely do some catastrophic/self insure combination. If we do include an evacuation plan, would we evacuate from the U.S. to find reasonable healthcare. Hmmm...

10 comments:

Mike,We too have been looking at this issue and had many of the same thoughts as you. Unfortunately as long as you are a citizen of the US you will have to carry insurance under the Affordable Care Act or else pay the penalty. Our tax guy sent us an estimate of our penalty and it will be cheaper to buy insurance. I'll email you the quote we just got from Anthem so you can see.

If there were "affordable" options that would be fine...sadly all I can tell at the moment is that the "Affordable Care" act helped insurance companies slip their hands into our wallets and made things less affordable. I do need to research more so I hope I'm mistaken.

My brother-in-law is an expatriate living outside the US and initial research indicates he is exempt: http://americansabroad.org/issues/healthcare/obamacare-does-not-apply-abroad/ so further research may reveal alternatives...I hope.

You have my email and any info you are up for sharing would be greatly appreciated.

What people don't realize is that obamacare now taxes the insurance companies at a very high rate. This is passed to the customer obviously. They couldn't get the tax increase on the citizen directly so they did it this way. My health care costs is almost double since Obamacare.

Yep, the thing we really needed to get rid of are the insurance companies themselves instead of forcing everyone to buy an insurance policy from them. It amazes me that so many other countries can manage some basic level of care for their population, but all we can do is force people to buy policies for companies so their executives can make exorbitant salaries and "pass along" everything including the result of their greed to the rest of us.

The good news is that if you've living abroad, you will not be required to purchase health insurance or pay a fine for not doing so. The bad news is that unless you rent an apartment or buy a house in another country (e.g have an actual physical overseas address), you won't be living abroad. You'll be traveling on a boat that will be registered in the US, and as far as the government is concerned, you'll be a US resident subject to the rules of Obamacare. More bad news - because the law requires the insurance policy you carry to cover a wide range of "free" preventive care and services as a sop to a broad coalition of Democrat constituencies, the insurance will be very expensive. You will not have the option of buying a low cost, high deductible catastrophic policy, you'll have to buy one that provides "free" mamograms, birth control, reproductive health services, etc. Good news - the fines will be means tested, so if you're not working, off cruising on a sailboat, your income may be low enough to qualify you for reduced or even waived fines for not purchasing insurance. And besides, as the ultimate insanity, if you actually get sick and need to return to the US for care, the "pre-existing conditions" requirement means you can then purchase insurance. And then cancel it again as soon as you're better and go back to paying the fine. Nice plan they put together.

Thanks for the info. In case my post indicated that I was frustrated at one of the political parties in the healthcare mess in the US, I was not. I think both are equally culpable in the mess.

On the bright side, when I checked the cost of coverage just a couple days ago, it appears to have gone down a little from what it was when I checked a couple months back. Hope it continues that trend.

Here's the best advice I can give you. Get the least expensive, most restrictive policy you can find offered by one of the major carriers. Personally I recommend Blue Cross/Blue Shield. They typically offer as their least expensive plan one that locks you in to only being able to use preferred providers, and this restriction lowers your rate. The unknown secret is that once you're out of the US, BCBS treats ALL medical providers as preferred providers (probably due to the much lower cost of receiving care outside the US). You'll have to pay for your care upfront and then file for reimbursement, but BCBS maintains a customer service center you can reach 24/7 via toll free phone and fax, and they have translation and conversion capabilities for when the only paperwork you've received is in a foreign language and currency. Other companies, not so much. And no, I don't work for them. :-)

FYI if it matters, the accounts of other cruisers I've read seem to indicate that in most of the world, care is comparable to what you'd receive in any small to medium sized US city. It's only if you're used to Mayo Clinic/ John's Hopkins type care that you might be a little disappointed.

Hi Mark, My concern is if those types of policies will qualify under the new U.S. laws that take effect in 2014. If not, my wife and I may be required to purchase other insurance or pay a fine for not having a "qualifying" plan (or try to become a citizen of somewhere else...which does sound appealing sometimes). Unfortunately somewhere along the way, the idea of providing a basic level of care to all U.S. citizens seems to have turned into a requirement for all U.S. citizens to help fund insurance companies.

...That's the plan anyway

With no sailing experience and coming from a land-locked state, we intend to give up successful careers and embark on a more minimalistic and lower impact lifestyle living on a sailboat. Come along as we attempt to sail away from the rat race.

About Me

I'm an ex-software engineer living with my wife and two spoiled dogs. I hold a private pilots license and in the past owned a small, single engine aircraft. My wife and I are both PADI certified open water scuba divers.
When we started this sailing adventure, other than being passengers, we had no experience on a sailboat. We've taken sailing lessons through the ASA programs in both Colorado and Florida. In December 2013 we purchased our floating home, a 1999 Leopard 38, and in April of 2015 we sold our house and moved aboard.